WebMD Chief Medical Officer, John Whyte, MD, MPH, speaks with Anne Klibanski, MD, on the future of academic medicine.
This transcript has been edited for clarity.
John Whyte, MD, MPH: If you have a health condition that's hard to manage or one that's difficult to diagnose, where do you go? Usually, it's an academic medical center. These institutions are often at the forefront of research and clinical excellence. They are a critically important component of our healthcare system. Yet, they're facing enormous challenges right now. I recently sat down with Dr Anne Klibanski, the president and CEO of Mass General Brigham, who explains how the role of academic medicine has changed. We debate whether innovation needs to be patient-centric or patient-driven and what impact tech is having, and should have, on your health. She also shares her leadership style and responds to whether there is an elitism that still exists at some centers. It's a frank but also comprehensive discussion about academic medicine.
Dr Klibanski, thanks for joining me today.
Anne Klibanski, MD: Thank you very much for having me. Pleasure to be here.
Whyte: I want to start off with, what's the role of academic medicine today?
Klibanski: Academic medicine has always been a way to take the very best of science, of innovation, and translate it into the highest level of clinical care. Right now, the role is increasingly threatened because all of the pressures that are upon all healthcare systems: keeping that spirit, keeping those resources, keeping that commitment, and keeping all of what we do in academics and bringing the science, the thinking forward to advance therapeutics, diagnostics, procedures — all of that needs to be maintained, to keep healthcare in this country at the forefront of pushing the boundaries of what health should be in the future.
Whyte: Those are all the positive things. You know, we'd expect to hear that at Mass General Brigham, one of the premier healthcare institutions. But what about people who say, "Dr Klibanski, academic medicine is too old. It's too expensive; it's too patrician" — town vs gown? And I want to read you a quote from an article from the Harvard School of Public Health. It just was published. It's a great headline. It says, "Public health needs to stop being so smug." Is there an elitism that exists at academic institutions?
Klibanski: The important thing is to separate out the intent and the function and the purpose of academics from the trappings of a lot of the tradition and some of the rigidity and, I'll say, calcification. The way medicine is practiced is so rapid, it's so fast-paced, it's so nimble and can be so flexible. That is what has to be put into academic medicine. If I think about healthcare delivery, and I think about the practice of medicine and the care that's actually delivered, they've been revolutionary. The actual impact of how care is delivered… That's an incredible area of focus, innovation, and priority — and it should be. The goal here is to take academic structures that have been largely unchanged, sometimes for decades or longer, and say that the core values here of academics need to be brought into sync with where we need to go in terms of healthcare delivery. So the short answer is that yes, there is some elitism and smugness that had been there for a long time. But the challenge in academic medicine is to determine the core things we need to move forward, that will move us into the future. How do we separate that from the rigidity of the past?
Whyte: But the rigidity of the past, many will argue rightfully, has promoted disparity, has promoted discrimination, this elitism, that we know what to do and we know how you need to be treated. That's exactly opposite of this concept of patient centricity. I want to go back to a quote that's in your bio on your website. It says you're "building a healthcare system of the future with patients at the center by transforming care." What does that mean on a practical level to viewers? How are you transforming care?
Klibanski: Everything that we need to do in healthcare needs to relate to patients; it's all about patients. At the heart of everything we do as a healthcare system, we have to put patients first. That is taking the very best of academic medicine and putting it into healthcare in a way that will provide the care for patients. If we look at patient care, we have to think about it as the entire continuum of care, care that's delivered in very different places: in the home, in the community, in different settings, in the hospital, back in the home. We have to look at that whole continuum of care and ask, how do we have the best patient outcomes? How do we have the best patient experience? And how do we take the best of science and discovery and innovation and put that into the equation? If you're a researcher, at the end of the research — at the end of the papers, and the grants, and all the work that you've done — is a fundamental discovery that will help us understand a disease better, and that can translate into diagnostics that will help patients be diagnosed earlier. It will help those clinicians to take better care of patients. We're always learning from what we do. And we're taking those learnings and putting them into things that will better help patients.
Whyte: But how do we decide what's important in this concept of patient centricity? There's some discussion on social media that I want to get your reaction to: that patient centricity isn't even the right phrase we should be using. Instead of "patient-centered," should we use "patient-driven"? And you could say, "You know, John, that's semantics." But is there a difference?
Klibanski: "Patient-centered" is often used as a way of saying an institution, a group of people, will decide who is making the decisions, and what really is it based on? The way we have approached this as an institution, as a healthcare system, is to ask the question of many, many different patients in many, many different settings. What are those things that matter to you, in contrast to those things that may matter to your physician or your caregiver? We have really pioneered the use of patient-reported outcomes, and that is a very objective way of seeing what it is that patients are experiencing, what their needs are, and what that looks like. We have really focused on this as a way of answering these questions in a very rigorous and deliberate manner. After surgery, for example, the concern of the surgeon is going to be a set of things: They are dealing with quality, safety, with those things that are really important in medical care. But what the patient may be thinking about is, how long does it take them to walk out of a room? What kind of pain are they feeling in the middle of the night? These may not be top of mind, but they are top of mind for patients. Looking at those patient-reported outcome measures has been a very important way that we as a healthcare system are really moving this forward and taking the best of where we're going diagnostically and therapeutically, and putting that all together.
Whyte: I want to turn to some innovations that you're taking the lead in, specifically around artificial intelligence (AI) and cancer. You have a study going on about AI in lung cancer, looking at low-dose CT scans, and then using predictors to determine who needs additional screening. But you're not actually using social determinants of health, something we've been talking a lot about in terms of the predictions. So where are we in the use of AI, balancing these multiple dimensions that you've just referenced in terms of patient care?
Klibanski: Fundamentally, so much of this deals with your data, the integrity of your data, and who is in that dataset. When we're talking about things like social determinants of health and bias in data and who's in the dataset, you need a very broad dataset. You need to include people of all different ethnicities, all of the different factors that really determine social determinants of health. Otherwise, you're starting with a very biased dataset. But fundamentally, what we're doing is taking that very rich curated dataset and asking, what are the things that you can use that are already there to make predictive models so that you can diagnose things earlier? How critical is that? I mean, we are now seeing so much delayed care post-COVID. We are seeing upticks as are being seen around the country, and our patients, who are coming in with more cancers, cancers at an advanced stage… When we roll out many of these predictive models, we will be able to diagnose these cancers earlier; we will be able to understand what those things are that will help us in making these predictions, and that will enable us to treat patients earlier and hopefully see more cures in those patients.
Whyte: Can you talk about this longitudinal care and using electronic health systems to do that? That assumes that the patient is part of electronic health system or stays part of it. I might use trackers, smart devices, what I'm calling smart jewelry, that give me data about my heart rate — whether I'm in atrial fibrillation or not — and can tell me indications about my sleep quality. We both have been around long enough to know about interoperability. We're still talking about it —that those data are not going to get into the health record. So how do we address this? More and more, healthcare is becoming retail. We all did COVID tests at home, pulse oximetry — all those data didn't get to the doctor. So how are you addressing this issue of wanting patients to do care at home? We want to provide care to where patients are. But does that sometimes leave the healthcare system as we currently think about it out of the mix?
Klibanski: Yes. How do we broadly adapt technology in a way that is better for patient care? Bringing in these datasets is very important. What are we doing in the home? And how do we use technology-enabled devices, data collection, to actually improve that? If you use technology and you partner with many of these companies that are the technology providers, to enable us to better use and import the technology, what you have then, ideally, is a lot of the best of both worlds.
Whyte: Dr Klibanski, what do you say to people who will argue that Boston's an anomaly? I can't spit and not hit a teaching hospital. There are so many healthcare institutions — higher learning in a very small, concentrated area. There are plenty of healthcare providers I can find to go into a person's home. That might not be as generalizable in other cities. So is what you're doing here generalizable to the broader population?
Klibanski: We do have a number of academic healthcare systems in Boston, no question about it. But the reality is that there is so much patient demand out there. And it's not just COVID. But you have an aging population; you have many patients with illness, with diagnosed illness, with undiagnosed illness.
Whyte: Heart failure, diabetes, coronary artery disease…
Klibanski: Everywhere, everywhere. All of that is just increasing. The reality is this: Despite the number of teaching hospitals, despite the number of community hospitals, despite the number of healthcare systems in Boston in the state, there's no capacity. That capacity is driven by space by those challenges but also by the number of providers. It is very, very difficult to get an appointment. It is very, very difficult to find a primary care provider. These are fundamental problems in all of these healthcare systems, including Boston, with our enormous number of teaching hospitals. So, what do we do about it? How do we scale this up? Some of the ways to scale this up is to really rethink how we are delivering health. We have to absolutely disrupt that model because fundamentally, it only works for those patients who have access to the system. You have to look at the continuum of care. The first question is: What is it that you can provide in the home? How does it get provided? Who provides it? In the home, there are things that one can do to self-monitor that don't require anyone's intervention. Think about a thermometer. What's the intervention that's needed there? Those have been around for many years. You take your temperature and either it's normal or it's not. If it's not, you go in a certain direction. But if I think of the thermometers of the future, there are many, many devices. And you've already mentioned some of these that can sail free; they can tell you when there's an alarm, when there's something that needs to be tested. I think the most important concept here is that we have to look at the continuum of care. We have to start by understanding what care is provided by whom. If you talk about care in the home, one of the things you mentioned early on is, do you think you have enough doctors to go out and do this? The answer is no. We just don't. But who do you need to provide that care? Is it doctors? Is it nurses? Is it advanced nurse practitioners? Is it any number of a whole category of people? You don't need to send a doctor into the home.
Whyte: What do you see as the biggest threat today to academic medicine thriving and doing all the things that you say we need to do to continue to transform care?
Klibanski: The immediate threat in terms of some of the things that we're talking about, in terms of best care for patients and lowering cost of care and how to scale it up, I think you've mentioned two of them. The regulatory environment is highly problematic. We really have to talk about cross-licensure in a way that enables providers in states where they may have more providers to actually provide that care somewhere else. If I look at, for example, pediatric psychiatry, which is an incredibly unmet need, there are more pediatric psychiatrists who really understand and work in this area at one of our hospitals than there are in many — half or more — states. So we have to be able to get expertise out there, where it's needed. There has to be parity or there will be fundamental problems in adoption. If I look at how behavioral health has been revolutionized post-COVID, it's not nearly where it should be. But the use of virtual health is still at about 80%. Once you start moving that in terms of parity, you're going to get lower adoption; it's going to hurt patient care. So I agree with what you're saying, that there are solutions to that but there has to be a willingness to deal with that. The fundamental threats to academic medicine are somewhat related. But actually, I think that it can be categorized maybe a little bit differently. The fundamental model by which academic systems survive financially is very much under siege right now. If you look across healthcare and you look at all of the healthcare systems and the hospitals and what's going on, there are trends there that are very disturbing. Number one is obviously the number of patients who are uninsured, the number of patients who don't have access. These are huge problems in terms of the health of the country, specifically in terms of academics. Though for us, we are a large, not-for-profit healthcare system. What that means is we don't have shareholders, we have patients. The profits that are generated get plowed right back into the system. This is what funds the higher-level tertiary, quaternary care, which is more expensive. This is what funds research. In addition to the grants and philanthropy, it is what funds research and training and innovation. That is at the core of academic medicine; 60% of our cost is in people, inflation, the cost of care. All of these things are fundamentally threatening. The worry in academic healthcare is that because of so many of the problems with the financing of healthcare, many healthcare systems will stop investing in academic medicine. They will stop investing in research. They will stop investing in researchers. That is fundamentally threatening; who is going to innovate? Who is going to move that science in a direction that will translate into patient care? The universities may continue, but taking all of that discovery, bringing it to the bedside, and translating it into care that will better diagnose and treat and help those patients, that's at the heart of academics. That is fundamentally what is being threatened.
Whyte: I want to turn to leadership. As I walked into this complex today, there's a lot of portraits all around the building. The portraits primarily are of White men. And here we are today. You're the president and CEO. What statement, first of all, does that make?
Klibanski: When I first became CEO in 2019, one of the questions I was asked was, "How do you feel about being the first woman CEO of Mass General Brigham?" And I said, "I am waiting for the day when that question is no longer asked, when people will say, 'How does it feel to be the CEO of Mass General Brigham?'" Or pick any company or country or whatever. That will no longer be a question. Because what we are going to be looking at is who the person is in that leadership position as opposed to the first woman, the first person of color. When I look at all of the portraits, I see a few things. I see the positive history of culture of those things that have been developed by people who were there at the time. But what I also see is the deep-seated feeling that people have when they look at a wall a hallway of portraits and say, "I don't see myself there." If we look at the trainees in medicine who are coming in, what do we see? We see people who are representative of people in this country — not as much as it should be but much, much more in that direction. We see more women, people of color. And when these people who are the future of all of what we're talking about look at those portraits, I want them to see portraits of people so that they can say, "That could be me."
Whyte: What's your leadership style?
Klibanski: My leadership style is to think through where we're going and why. I like to focus on the why. Where are we going as a healthcare system? You read something from the website earlier about what really is "where we're going"? What is that statement? You have to think, What's the why of that? Why are we doing this? If we're doing this for patients, why are we doing this? What does that mean? Leadership-wise, it's having people at multiple levels of an organization; we're over 80,000 people. People do so many different jobs here. So how do you collectively take an organization and decide how to move people into the future when they're still trying to figure out what the past or the present is? A lot of it is embracing a vision, focusing on the why, listening to people, but then making decisions and really sticking to those decisions — making a decision and saying, "This is what we're doing. This is why we're doing it. This is how we're doing it." There are going to be huge obstacles, but you need to keep doing it. You also have to keep learning. I stressed before that we're a learning institution. What have we done that's worked? What have we done that hasn't worked? You have to learn as you go and be nimble enough and humble enough to listen and to change according to what's happening.
Whyte: What can other healthcare institutions learn from what you're doing here at Mass General Brigham?
Klibanski: I think the thing that we all are struggling with is, how do we get beyond the tyranny of the moment and keep our eye on the future? How do we invest in the future, in the future of our people, in the future of what we envision the best care for patients will be and needs to be? How do we keep focusing on, investing in, and envisioning and enabling that future in a way that enables us to deal with all of the crises at hand but not taking our eye off of that?
Whyte: Dr Klibanski, thank you very much for your time today.
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Cite this: Change Makers: Dr Anne Klibanski on Transforming Academic Medicine - Medscape - Mar 28, 2023.